Guardian Angel Hospice Inc.

“Based on record review and interview, the agency failed to ensure the frequency of services on the plans of care were patient specific in 15 of 18 active patients reviewed (Patient #1, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17), with the potential to affect all patients. Findings include: A review of the clinical record of Patient #6 included a plan of care for 02/04/24 – 04/03/24 that indicated frequency orders for the skilled nurse (SN) of 1 time a week for 9 weeks and 10 prn (as needed) visits, hospice aide 2 times a weeks for 8 weeks and 10 prn visits, chaplain 1 time a month for 2 months and 10 prn visits, and social workers 2 times a week for 2 months and 8 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. During an interview on 03/22/24 at 2:45 PM, when asked for the reason of ordering the number of prn visits, RN 8 indicated had been instructed to add the large number of SN prn visits in case the patient has a change of condition and needed a visit and the prn visits for the hospice aide in case they were needed for unexpected visits. A review of the clinical record of Patient #8 included a plan of care for 02/22/24 – 05/21/24 that indicated frequency orders for the SN 1 time a week for 1 week and 10 prn visits, hospice aide 10 prn visits, chaplain 10 prn visits, and social worker 1 time a month for 3 months and 10 prn visits. Review of an order dated 02/26/24 indicated 30 prn visits for the social worker. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. During an interview on 03/21/24 at 12: 50 PM, when asked why the SN, hospice aide, social worker, and chaplain have a large number of prn visits, RN 9 indicated the admission nurse enters the extra prn visits in case the patient falls or must go out after hours. A review of the clinical record of Patient #9 included a plan of care for 01/27/24 – 3/26/24 that indicated frequency orders for the SN 1 time a week for 9 weeks and 20 prn visits, hospice aide 2 times a week for 8 weeks and 20 prn visits, and chaplain 3 times a month for 2 months and 15 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. During an interview on 3/21/24 at 3:35 PM, when asked why the scheduled visit orders are not changed according to the patient needs instead of entering a large number of prn visits, RN 10 indicated the prn visits are entered in case there is a patient concern, emergency need or after death care needs. A review of the clinical record of Patient #10 included a plan of care for 02/02/24 – 05/01/24 that indicated frequency orders for the SN 1 time a week for 12 weeks and 10 prn visits, hospice aide for 10 prn visits, chaplain for 10 prn visits, and the social workers for 10 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. During an interview on 03/21/24 at 3:37 PM, when asked for the reason in entering 10 prn visits for the disciplines, RN 11 indicated was instructed to enter the quantity of prn visits in case a visit was needed. During an interview on 03/21/24 at 3:57 PM, when asked if either a hospice aide or social worker visit Patient #10, RN 2 indicated both disciplines were declined. When asked to explain why 10 prn visits were ordered for the hospice aide and the social worker, RN 2 indicated the prn orders were entered in case the patient has a sudden need for a visit. A review of the clinical record of Patient #11 included a plan of care for 02/06/24 – 05/05/24 that indicated frequency orders for the SN 1 time a week for 12 weeks and 10 prn visits, hospice aide 2 times a week for 12 weeks and 10 prn visits, chaplain 2 times a month for 3 months and 10 prn visits, and social worker 10 prn visits. Review of the interdisciplinary group meeting dated 03/21/24 included orders dated 03/06/24 for the social worker to visit 2 times a month for 2 months and 30 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. A review of the clinical record of Patient #12 included a plan of care for 02/19/24 – 05/18/24 that indicated frequency orders for the SN 2 times a week for 13 weeks and 15 prn visits, hospice aide 2 times a week for 13 weeks and 10 prn visits, chaplain 10 prn visits, and social worker 1 time a month for 3 months and 10 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. A review of the clinical record of Patient #13 included a plan of care for 02/09/24 – 04/08/24 that indicated frequency orders for the SN 1 time a week for 8 weeks and 20 prn visits, hospice aide for 2 times a week for 8 weeks and 20 prn visits, social worker 1 time a month for 2 months and 30 prn visits, and chaplain 1 time a month for 1 month and 2 times a month for 1 month and 10 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. During an interview on 03/20/24 at 9:00 AM, when asked to explain why the number of prn visits were ordered, RN 1 indicated was told by the agency to put in 20 prn visits for the SN and 10 prn for the hospice aide and indicated the social worker and chaplain put in their own orders. A review of the clinical record of Patient #14 included a plan of care for 01/29/24 – 04/27/24 that indicated frequency orders for the SN 2 times a week for 1 week, 1 time a week for 11 weeks and 10 prn visits, hospice aide 10 prn visits, chaplain 2 times a month for 3 months and 10 prn visits, and social worker 10 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. During an interview on 03/20/24 at 10:15 AM, when asked why 10 prn visits were entered for the patients, RN 3 indicated the prn visits are entered at the admission visit. When asked who is responsible for updating the frequency orders, RN 3 indicated the RN enters visit orders for the SN and the hospice aide, and the social worker and chaplain enter their own frequency orders. During an interview on 03/20/24 at 1:55PM, when asked for the frequency orders Patient #14, social worker 2 indicated had forgotten to enter specific visit orders. When asked how the frequency orders are determined, social worker 2 indicated they are determined after the family and patient evaluation is completed. When asked to explain the reason for entering 10 prn visits, social worker 2 indicated they were entered by the admission nurse in case a visit is needed. A review of the clinical record of Patient #17 included a plan of care for 03/06/24 – 05/04/24 that indicated frequency orders for the SN 1 time a week for 9 weeks and 20 prn visits, hospice aide 2 times week 1, 3 times a week for 8 weeks and 20 prn visits, and the chaplain 4 times a month for 2 months and 1 time a month for 1 month and 10 prn visits. The plan of care failed to evidence visit frequencies specific to patient needs with the addition of the large number of prn visits. During an interview on 03/19/24 at 3:30 PM, when asked why 10, 20, and 30 prn visits are entered as orders for discipline visits, the director of nursing indicated did not know. During an interview on 03/22/24 at 9:10 AM, when asked if a patient declines chaplain visit would prn visits be ordered, chaplain 2 indicated prn visits are ordered in case a visit is needed. A review of the agency policy on plans of care indicated the plan of care was specific “;... to the care and services necessary to meet the needs of the patient ....” A review of the clinical record for Patient #1, benefit election date of 2/15/2024, evidenced a plan of care (POC) which included the frequency of services needed to meet Patient #1s needs. In addition to routine visits, the POC evidenced “;as needed” (PRN) visits for a change in condition or need. The PRN visits included 15 skilled nurse visits, 10 aide visits, and 8 medical social work (MSW) visits. During an interview on 3/22/2024 at 3:43 PM, registered nurse (RN) 4 indicated they added 15 PRN nurse and 10 aide visits per agency practice. During an interview on 3/22/2024 at 1:40 PM, MSW 1 indicated the practice was to add PRN visits for 8 weeks and usually allowed for 2 visits per week. A review of the clinical record for Patient #3, benefit period 2/7/2024 – 5/6/2024, evidenced a plan of care (POC) which included the frequency of services needed to meet Patient #3s needs. In addition to routine visits, the POC evidenced “;as needed” (PRN) visits for a change in condition or need. The PRN visits included 20 nurse and 20 aide visits. During an interview on 3/22/2024 at 12:30 PM, RN 2 indicated they were trained to include 20 visits just in case the visits were needed. A review of the clinical record for Patient #5, benefit election date of 1/13/2024, evidenced a plan of care (POC) which included the frequency of services needed to meet Patient #5s needs. In addition to routine visits, the POC evidenced “;as needed” (PRN) visits for a change in condition or need. The PRN visits included 10 nurse, 10 aide, and 10 MSW visits. During an interview on 3/22/2024 at 12:39 PM, RN 7 indicated they add 15 visits just in case. These are included at admission and every recertification period. During an interview on 3/22/2024 at 12:45 PM, MSW 3 indicated they always added 10 PRN visits. A review of the clinical record for Patient #4, benefit period 2/8/2024 – 5/7/2024, evidenced a plan of care (POC) which included the frequency of services needed to meet Patient #4s needs. In addition to routine visits, the POC evidenced “;as needed” (PRN) visits for a change in condition or need. The PRN visits included 20 nurse and 20 aide visits. During an interview on 3/22/2024 at 1:47 PM, RN 5 indicated they just put in 20 nurse and aide visits as standard practice. A review of the clinical record for Patient #15, benefit election date 1/23/2024, evidenced a plan of care (POC) which included the frequency of services needed to meet Patient #15s needs. In addition to routine visits, the POC evidenced “;as needed” (PRN) visits for a change in condition or need. The PRN visits included 10 nurse and 10 aide visits. During an interview on 3/22/2024 at 12:23 PM, RN 6 indicated each patient received 10 PRN visits at admission, though they werent sure why. RN 6 indicated it was “;fairly easy” to get new orders when needed. A review of the clinical record for Patient #16, benefit period 2/13/2024 – 4/12/2024, evidenced a plan of care (POC) which included the frequency of services needed to meet Patient #16s needs. In addition to routine visits, the POC evidenced “;as needed” (PRN) visits for a change in condition or need. The PRN visits included 10 nurse and 10 aide visits. During an interview on 3/22/2024 at 1:47 PM, RN 5 indicated their typical practice was to include 20 visits for the certification period.”

“Based on record review and interview, the agency failed to ensure the plan of care (POC) included the dose of medications in 5 of 7 active records reviewed for patients residing in their home (Patient #1, 2, 10, 12, 16) and failed to ensure the POC included orders for all medications used in 1 of 7 active records reviewed for patients residing in their home (Patient #12). Findings include: A review of the clinical record for Patient #1 evidenced a plan of care (POC) which included a medication list. The POC included haloperidol milliliters 0.5 oral, every 6 hours as needed for agitation. The medication also included morphine milliliters 0.25, oral every 3 hours as needed for pain. The POC failed to identify the strength of haloperidol and morphine. A review of the clinical record for Patient #2 evidenced a plan of care (POC) which included a medication list. The POC included haloperidol milliliters 0.5 oral, every 6 hours as needed for agitation. The medication also included morphine milliliters 0.25, oral every 3 hours as needed for pain. The POC failed to identify the strength of haloperidol and morphine. A review of the clinical record for Patient #16 evidenced a medication profile. The profile included haloperidol milliliters 0.5 oral, every 6 hours as needed for agitation. The medication also included morphine milliliters 0.25, oral every 3 hours as needed for pain. The medication profile failed to identify the strength of haloperidol and morphine. During an interview on 3/22/2024 at 2 PM, the director of nursing (DON) indicated haloperidol and morphine were part of a “;ComfortPak” (package of medications commonly used at end of life), in which was entered as a pre-written order set. During a demonstration of the order set in the electronic medical record, both haloperidol and morphine included the correct dosage and strength of the medication. The DON indicated the electronic medical record failed to include the strength of the medications when pulled to the medication profile and plans of care. The DON indicated this was a problem with the electronic medical record. Review of an agency policy titled “;Plan of Care-Content” indicated the POC includes drugs necessary to meet the needs of the patient. A review of the clinical record of Patient #10 included a plan of care for 02/02/24 – 05/01/24 that indicated the following medications: haloperidol millilters (measure of volume in metric system) 0.5 oral, every 6 hours as needed for agitation and morphine milliliters 0.25 oral, every 3 hours as needed for pain or shortness of breath. The POC failed to evidence the dose for administration of haloperidol and morphine. During an interview on 03/21/24 at 3:37 PM, when asked to provide the dose of haloperidol, RN 11 indicated the order is missing the dose. When asked to provide the dose of morphine, RN 11 indicated the order is missing the dose. A review of the clinical record of Patient #12 included a plan of care for 02/19/24 – 05/18/24 that indicated the following medications: haloperidol millilters 0.5 oral, every 6 hours as needed for agitation and morphine milliliters 0.25 oral, every 3 hours as needed for pain or shortness of breath. The POC failed to evidence the dose for administration of haloperidol and morphine. During an interview on 03/22/24 at 10:58 AM, RN 11 indicated the dose for both medications is not showing up in the electronic medical record. Review of a Skilled Nursing Visit Note dated 02/22/24 indicated RN 8 brought antifungal powder to the home of Patient #12 to be used for a fungal infection in the groin area. Review of the POC and orders failed to evidence orders for antifungal powder. During an interview on 03/22/24 at 12:42 PM, when asked where the order for the antifungal powder can be found, RN 8 confirmed the antifungal powder is being used with Patient #8 and has not obtained an order.”

“Based on record review and interview, the interdisciplinary team (IDT) failed to ensure revisions were made to the plan of care (POC) for 3 of 7 active records reviewed of patients residing in nursing facilities (Patient #6, 9, 17) and 1 of 3 active records reviewed of patients residing in assisted living facilities (Patient #13). Findings include: 1. Review of an agency policy titled “;Interdisciplinary Team” indicated the IDT is responsible for revising the patients plan of care. 2. A review of the clinical record of Patient #6, benefit election date of 02/14/22, included a POC for 02/04/24 – 04/03/24 that included orders for changing the date of a hospice aide visit on 11/24/22 and a skilled nurse (SN) visit on 04/07/23. The POC included target dates of completion as 11/03/23 for SN goals. The POC failed to evidence that revisions were made to all orders and goals. During an interview on 03/22/24 at 2:45 PM, when asked why the current POC included one-time orders from previous benefit periods, registered nurse (RN) 8 indicated they should have been removed. When asked why target dates for goals of previous benefit periods were in the POC, RN 8 indicated he/she was behind in updating the plan of care. 3. A review of the clinical record of Patient #9, benefit election date of 08/05/22, included a POC for 01/27/24 – 03/26/24 that included orders for changing the dates of hospice aide visits on 12/23/22, 03/23/23, 03/30/23, 07/04/23, 08/21/23, and 11/24/23. The POC included target dates of completion as 12/11/23 for IDT goals. The POC failed to evidence that revisions were made to all orders and goals. During an interview on 03/21/24 at 3:35 PM, when asked why the current POC included one-time orders from previous benefit periods, RN 10 indicated it was not an active order and was not discontinued. When asked why target dates for goals of previous benefit periods were in the POC, RN 10 indicated they werent revised. 4. A review of the clinical record of Patient #13, benefit election date of 04/15/23, included a POC for 02/09/24 – 04/08/24 that included documentation identified as SN interventions for patient falls that occurred on 08/01/23, 08/10/23, 08/15/23, 10/03/23, and11/08/23. The POC failed to evidence that revisions were made to all interventions. During an interview on 03/20/24 at 9:00 AM, when asked why falls with dates from previous benefit periods were included in the current POC, RN1 indicated he/she had been instructed to enter falls as interventions in the POC. 5. A review of the clinical record of Patient #17, benefit election date of 11/17/21, included a POC for 03/06/24 – 05/04/24 that included orders for changing the dates of hospice aide visits on 05/29/22, 10/26/22, 12/23/22, 12/26/22, 01/02/23, 05/29/23, 11/24/23, and 12/22/23. The POC included target dates of completion as 11/06/23 for hospice aide goals and 03/05/24 for SN goals. The POC failed to evidence that revisions were made to all orders and goals. During an interview on 03/20/24 at 1:00 PM, when asked why orders completed in previous benefit periods were included in the current POC, RN 2 indicated the orders should have been resolved. When asked why target dates for goals for previous benefit periods were in the POC, RN 2 indicated he/she did not know.”

“Based on record review and interview, the registered nurse (RN) failed to ensure a hospice aide written plan of care (POC) was developed for 1 of 5 active records reviewed of patients residing in a home receiving hospice aide services (Patient #8) and for 1 of 7 active records reviewed of patients residing in a nursing facility receiving hospice aide services (Patient #11). Findings include: 1. Review of an agency policy titled “;Hospice Aide Services” indicated the hospice RN develops a written hospice aide POC that provides instructions to the hospice aide of the patient-specific care to be provided. 2. A review of the clinical record of Patient #8 for benefit period 02/22/24 – 05/21/24 indicated orders dated 02/27/24 for the hospice aide to visit patient two times a week for 12 weeks. Review of the Aide Care Plan identified interventions with start dates of 03/11/24. Review of hospice aide documentation evidenced the hospice aide visited Patient #8 on 02/27/24, 02/29/24, 03/05/24, and 03/07/24. Documentation failed to evidence the hospice aide had a written POC before providing services. During an interview on 03/21/24 at 12:50 PM, when asked when the hospice aide POC was developed, RN 9 indicated interventions were entered on 03/11/24. When asked how a hospice aide would know what patient tasks to complete without a written POC, RN 9 indicated he/she would give the hospice aide verbal instructions. When asked why a hospice aide POC was not developed before the hospice aide made a patient visit, RN 9 indicated he/she had gotten behind with numerous new patients over the past few weeks. During an interview on 03/21/24 at 1:36 PM, when asked how a hospice aide would know what tasks to complete for Patient #8 without a written POC, hospice aide 3 indicated the spouse of Patient #8 gave instructions. When asked how documentation is completed when the POC had not been developed, hospice aide 3 indicated he/she documented the tasks completed in the narrative section. 3. A review of the clinical record of Patient #11 for benefit period 02/06/24 – 05/05/24 indicated orders dated 02/12/24 for the hospice aide to visit Patient two times a week for 12 weeks. Review of hospice aide documentation evidenced the hospice aide visited Patient #11 on 02/13/24, 02/20/24, 02/23/24, and 02/27/24. Documentation failed to evidence the hospice aide had a written POC before providing services. During an interview of 03/22/24 at 11:06 AM, when asked how to know what tasks to complete at visit without a POC, hospice aide 3 indicated he/she document tasks completed in the narrative section. During an interview on 03/22/24 at 11:34 AM, when asked when the hospice aide POC was developed, RN 9 was not able to recall and indicated might have entered interventions a week ago. When asked how a hospice aide would know what tasks to perform without a POC, RN 9 indicated he/she had a phone conversation with the assigned hospice aide.”

“Based on record review and interview, the agency failed to ensure the hospice aide provided services following the plan of care (POC) for 1 of 5 active records reviewed of patients residing in a home receiving hospice aide services (Patient #8) and for 1 of 7 active records reviewed of patients residing in a nursing facility receiving hospice aide services (Patient #11). Findings include: 1. Review of an agency policy titled “;Hospice Aide Assignments and Duties” indicated a hospice aide provides services ordered by the interdisciplinary group and included in the POC. 2. A review of the clinical record of Patient #8 for benefit period 02/22/24 – 05/21/24 indicated orders dated 02/27/24 for the hospice aide to visit patient two times a week for 12 weeks. Review of the Aide Care Plan identified interventions with start dates of 03/11/24. Review of hospice aide documentation evidenced the hospice aide visited Patient #8 on 02/27/24, 02/29/24, 03/05/24, and 03/07/24. Documentation failed to evidence the hospice aide provided services following a POC for dates 02/27/24 – 03/07/24. During an interview on 03/21/24 at 1:36 PM, when asked how a hospice aide would know what tasks to complete for Patient #8 without a written POC, hospice aide 3 indicated the spouse of Patient #8 gave instructions. 3. A review of the clinical record of Patient #11 for benefit period 02/06/24 – 05/05/24 indicated orders dated 02/12/24 for the hospice aide to visit patient two times a week for 12 weeks. During an interview on 03/22/24 at 11:34 AM, when asked when the hospice aide POC was developed, RN 9 was not able to recall and indicated might have entered interventions a week ago. When asked how a hospice aide would know what tasks to perform without a POC, RN 9 indicated had a phone conversation with the assigned hospice aide. Review of hospice aide documentation evidenced the hospice aide visited Patient #11 on 02/13/24, 02/20/24, 02/23/24, and 02/27/24. Documentation failed to evidence the hospice aide provided services following a POC for dates 02/13/24 – 02/27/24.”

“Based on record review and interview, the registered nurse (RN) failed to perform a hospice aide supervisory visit every 14 days for 1 of 5 active records reviewed of patients residing in a home receiving hospice aide services (Patient #8). Findings include: 1. Review of an agency policy titled “;Hospice Aide Supervision” indicated an RN makes an on-site visit to the patients home no less frequently than every 14 days to ensure the services provided by the hospice aide are meeting the patients needs. 2. A review of the clinical record of Patient #8, benefit election date of 02/22/24, included a plan of care (POC) for 02/22/24 – 05/21/24 that included orders dated 02/27/24 for the hospice aide to visit Patient two times a week for 12 weeks. Review of the patient schedule evidenced no RN supervisory visit of the hospice aide made from the first visit made on 02/27/24 through 03/21/24. During an interview on 03/21/24 at 12:50 PM, when asked for the frequency of completing a hospice aide supervisory visit, RN 9 indicated every 14 days. When asked for the date a hospice aide supervisory visit was completed for Patient #8, RN 9 indicated he/she did not document the visit made on 03/05/24.”

“Based on record review and interview, the hospice agency failed to obtain a letter of accreditation from the contracted durable medical equipment (DME) providers for 1 of 1 hospice agency. Findings include: 1. Review of an agency policy titled “;Durable Medical Equipment” indicated the hospice maintains contracts with accredited DME providers. 2. Review of the Durable Medical Equipment Agreement documents for DME providers, Other B, Other C, Other D, and Other E, failed to evidence letters of accreditation. 3. During an interview on 03/22/24 at 3:00 PM, the administrator indicated the agency did not have a copy of a letter of accreditation from the contracted DME provider.”

“Based on record review and interview, the agency failed to ensure a patient in a skilled nursing facility (SNF) received care consistent with hospice orders for 1 of 1 patient (Patient #24), as reported by a hospice nurse, with the potential to affect all patients in a SNF. Findings include: A review on the agency contract with Entity A indicated the hospice was responsible for the professional management of patients in Entity A. A review of the agency complaint log evidenced a complaint reported on 11/10/2023. During the investigation of the complaint, licensed practical nurse (LPN) 1 expressed concerns that Entity A provided nutritional supplements against Patient #24s family request. During an interview on 3/21/2023 at 3:30 PM, the Administrator, director of nursing (DON) and the patient care manager (PCM), and chief executive officer (CEO) indicated the complaint was about LPN 1 and did not relate to a particular patient. The Administrator, DON, PCM, and CEO indicated they did not consider the concerns LPN 1 expressed about the patients care. They were unable to identify the particular patient at this time. They indicated the hospice was responsible for the professional management of their patients in SNFs. The CEO indicated they should have investigated the LPNs concerns. During an interview on 3/22/2024 at 3:45 PM, the PCM indicated they followed up with Entity A, identified the patient as Patient #24 and indicated Patient #24 did not receive nutritional supplements, but a dessert shake provided to all patients of Entity A. The Administrator, CEO, DON, and PCM indicated they should have investigated this at the time the concern was mentioned.”